Provider Demographics
NPI:1295519650
Name:WANEESON, WONGWANEE
Entity type:Individual
Prefix:
First Name:WONGWANEE
Middle Name:
Last Name:WANEESON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9925 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-5111
Mailing Address - Country:US
Mailing Address - Phone:310-842-9561
Mailing Address - Fax:
Practice Address - Street 1:6331 CANTILES AVE
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90630-5309
Practice Address - Country:US
Practice Address - Phone:213-479-0598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69689225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist